Compliance to therapy-elderly head and neck carcinoma patients

Utilization of radiation therapy and predictors of noncompliance among Syrian refugees in Turkey

Background

Access to cancer care is a problem that continues to plague refugees displaced from their home countries. The turbulent political crisis in Syria, which has led to millions of refugees seeking asylum in Turkey, merits further attention. We aimed to study the rate of utilization of radiation therapy among Syrian refugees with cancer living in Turkey in an attempt to identify the contributing factors predictive of non-compliance with prescribed RT.

Methods

In this retrospective review of 14 institutional databases, Syrian refugee patients in Turkey with a cancer diagnosis from January 2015 to December 2019 who were treated with RT were identified. The demographic data, treatment compliance rates, and toxicity outcomes in these patients were surveyed. Variable predictors of noncompliance such as age, sex, diagnosis, treatment length, and toxicity were studied. The association between these variables and patient noncompliance was determined.

Results

We identified 10,537 patients who were diagnosed with cancer during the study period, of whom 1010 (9.6%) patients were treated with RT. Breast cancer (30%) and lung cancer (14%) were the most common diagnoses with up to 68% of patients diagnosed at an advanced stage (Stage III, IV). 20% of the patients were deemed noncompliant. Treatment with concurrent chemoradiotherapy (OR 1.61, 95% CI 1.06–2.46, p = 0.023) and living in a refugee camp (OR 3.62, 95% CI 2.43–5.19, p < 0.001) were associated with noncompliance. Age, sex and treatment length were not significantly associated with noncompliance.

Conclusions

Noncompliance with radiotherapy among Syrian refugees in Turkey remains an area of concern with a multitude of factors contributing to these alarming numbers. Further studies to better ascertain the finer nuances of this intricately complex problem and a global combination of efforts can pave the way to providing a solution.

Compliance of Radiotherapy Treatment at a Tertiary Cancer Center in India—A Clinical Audit

Introduction Noncompliance to planned radiotherapy (RT) treatment is associated with inferior outcomes and also serves as an indicator of quality of care offered to the patients. Identification of the rate of noncompliance and its causative factors can help us develop an insight toward implementing mitigation measures thereby improving the quality of treatment.

Objective To ascertain the incidence of noncompliance and the factors affecting the same in patients offered RT appointments.

Materials and Methods We retrospectively reviewed the records of patients from January 1, 2019, to December 31, 2019, who were noncompliant (defaulted RT simulation or defaulted initiation of RT or defaulted planned RT during the course of RT but excluding planned/unplanned treatment breaks or early conclusions prescribed by the treating radiation oncologist) for the planned RT treatment.

Results Of the 8,607 appointments (7,699 external beam RT and 908 brachytherapy) given to the patients attending the radiation oncology outpatient department in the year 2019, a total of 197 (2.28%) patients were found to be noncomplaint. Ninety-seven patients defaulted RT simulation (49.2%), 53 defaulted RT starting (26.9%), and 47 defaulted while on RT (23.9%). Half of these had either head–neck (29.9%) or gynecological (20.8%) malignancies. Patients with breast cancers had the least noncompliance rates (0.02%). The cause for noncompliance was ascertained in 135 patients (68.5%). The common causes of noncompliance were the desire to continue treatment closer to home (21.5%) followed by logistic (17%), lack of confidence in the curative potential of the planned therapy (17%), and financial reasons (11.8%). Patients with head–neck and gynecological malignancies were more often with advanced staged disease and were planned multimodal treatment protocols. The majority of the 23 patients who defaulted palliative RT were planned for fractionated treatments (73.9%).

Conclusion The incidence of noncompliance in patients planned for RT in our institute can be considered optimum. Appropriate counseling of patients at the time of scheduling appointment, upfront identification of patients at high risk of noncompliance, and assisting patients with financial and logistic challenges are imperative to ensure adherence to planned treatment schedule.

A comparison of the MNA-SF, MUST, and NRS-2002 nutritional tools in predicting treatment incompletion of concurrent chemoradiotherapy in patients with head and neck cancer

BACKGROUND

Concurrent chemoradiotherapy (CCRT) treatment incompletion is a known negative prognosticator for patients with head and neck cancer (HNC). Malnutrition is a common phenomenon which leads to treatment interruption in patients with HNC. We aimed to compare the performance of three nutritional tools in predicting treatment incompletion in patients with HNC undergoing definitive CCRT.

MATERIAL AND METHODS

Three nutritional assessment tools, Mini Nutritional Assessment-Short Form (MNA-SF), Malnutritional Universal Screening Tool (MUST), and Nutritional Risk Screening 2002 (NRS-2002), were prospectively assessed prior to CCRT for HNC patients. Patients were stratified into either normal nutrition or malnourished groups using different nutrition tools. Treatment incompletion and treatment-related toxicities associated with CCRT were recorded.

RESULTS

A total of 461 patients were included in the study; malnourished rates ranged from 31.0 to 51.0%. The CCRT incompletion rates were 4.9-6.3% and 14.5-18.2% for normal nutrition patients and malnourished patients, respectively. The tools had significant correlations with each other (Pearson correlation 0.801-0.837, p<0.001 for all) and accurately predicted the incompletion of CCRT. MNA-SF had the highest performance in predicting treatment-related toxicity, including emergency room visits, need for hospitalization, any grade III or higher hematological adverse events, and critical body weight loss, compared to the other tools.

CONCLUSIONS

MNA-SF, MUST, and NRS2002 were all shown to be competent tools for prediction of treatment incompletion and treatment-related toxicity in HNC patients undergoing CCRT. We suggest implementing nutritional assessment prior to treatment to improve the rate of treatment completion and to reduce treatment-related toxicity in HNC patients.

Effects of Anesthetic Technique on Postoperative Pulmonary Metastasis in Patients Undergoing Laryngectomy

Background

Whether laryngeal cancer is directly implanted into the lungs during orotracheal intubation is still unclear. Therefore, this study aimed to find whether orotracheal intubation is an independent risk factor for postoperative pulmonary metastasis in patients undergoing laryngectomy.

Patients and Methods

Medical records from January 1, 2006, to December 31, 2016, were reviewed. According to similar propensity scores, patients who received orotracheal intubation (tracheal intubation group, n = 515) were matched 1:1 with those who received tracheotomy (tracheotomy group, n = 326) in the induction of general anesthesia. The primary outcome was postoperative pulmonary metastasis. Secondary outcomes included local recurrence, lymphatic metastasis, tracheostomal recurrence and overall survival.

Results

Between the two groups, there was no significant difference in postoperative pulmonary metastasis (P = 0.688), local recurrence (P = 0.215), lymphatic metastasis (P = 0.480), tracheostomal recurrence (P = 0.246) or all-cause death (P = 0.299). The primary site of cancer was an independent risk factor for pulmonary metastasis [HR 0.29, 95% CI 0.13–0.68; P = 0.013] and local recurrence (HR 2.69, 95% CI 1.39–5.21; P = 0.003). Type of surgery (HR 3.13, 95% CI 2.03–4.84; P < 0.001) and N classification of TNM (HR 0.27, 95% CI 0.10–0.75; P = 0.012) were risk factors for local recurrence. Postoperative chemotherapy was an independent risk factor for lung metastasis (HR 7.58, 95% CI 3.11–18.47; P < 0.001) and lymphatic metastasis (HR 5.18, 95% CI 2.57–11.91; P < 0.001), and 5-year overall survival was associated with age (P = 0.028), clinical stage (P < 0.001) and postoperative chemotherapy (P = 0.003) but not with anesthetic technique (P = 0.473).

Conclusion

This retrospective study suggests that orotracheal intubation in laryngectomy is not a risk factor for postoperative pulmonary metastasis, local recurrence, lymphatic metastasis or overall survival.

[Head and neck cancer in the elderly-current aspects]

BACKGROUND

The treatment of head and neck cancer is dominated by surgery and radiochemotherapy, which is in part associated with high morbidity. In elderly patients, however, the otorhinolaryngologist often has to question the rationality of invasive treatment. Although the proportion of geriatric patients with head and neck tumors is increasing, the paucity of data means that there are few consistent standards and recommendations in the literature and guidelines.

OBJECTIVE

The aim of this paper is to provide concrete clinical recommendations for geriatric patients with head and neck tumors based on a systematic literature search.

MATERIALS AND METHODS

A keyword-based literature search was performed to present the current level of evidence and provide a clinical algorithm.

RESULTS

In addition to age, the pretreatment dispositional evaluation of geriatric patients should include psychosocial, functional, and medical (patient history) comorbidities. For pretreatment risk stratification, an algorithm was created on the basis of these data for individual evaluation of the patient's pretreatment risk.

CONCLUSION

Pretreatment risk stratification of geriatric patients with head and neck malignancies is of high relevance for the individual decision for or against invasive treatment, but the currently available evidence is limited. This paper is based on a systematic literature review and provides a clinical algorithm for otorhinolaryngologists and head and neck surgeons.

Is Frailty Associated With Worse Outcomes After Head and Neck Surgery? A Narrative Review

OBJECTIVE

Frailty has emerged as an important determinant of many health outcomes across various surgical specialties. We examined the published literature reporting on frailty as a predictor of perioperative outcomes in head and neck cancer (HNC) surgery.

STUDY DESIGN

Narrative review with limited electronic database search and cross-referencing of included studies.

METHODS

PubMed was searched from inception until June 2019 to capture studies evaluating an association between frailty and perioperative outcomes among patients undergoing HNC surgery. Primary outcomes included mortality and morbidity, whereas secondary outcomes included in-hospital cost, length of stay, readmission, and discharge disposition.

RESULTS

We identified nine series examining frailty as a predictor of outcomes in HNC. The majority of studies (77%) identified patients using a large population-based database such as the National Surgical Quality Improvement Project or National Inpatient Sample. Frailty measures applied in the HNC surgery literature include the modified frailty index, Groningen Frailty Indicator, and John Hopkins Adjusted Clinical Groups frailty-defining diagnosis indicator. Most studies demonstrated a significant association between frailty and perioperative outcomes, including mortality, perioperative complications, and Clavien-Dindo grade IV complications. Furthermore, frailty was associated with greater length of hospital stay, readmission rate, and likelihood of discharge to short-term or skilled nursing facilities.

CONCLUSION

The current literature demonstrates the utility of frailty as a predictor of perioperative mortality and morbidity. Further research is needed to develop frailty screening measures in order to risk-stratify patients and optimize modifiable factors preoperatively. Laryngoscope, 130:1436-1442, 2020.

Experience of radiotherapy in head and neck

Abstract Objective: The aim of this manuscript was to understand and describe the experience of radiotherapy on the perspective of a woman with oral cancer. Methods: This is a qualitative, exploratory, descriptive study, with theoretical reference of medical anthropology and instrumental case study methodology. Data collection was performed in the oncology sector of a public university hospital in the Southeast region of Brazil, State of Minas Gerais, Brazil and at the participant’s residence, during from March to August, 2016. The case selected was of a female patient, diagnosed with Spinocellular Carcinoma in oral cavity, submitted to radiotherapy. Five semi-structured interviews and participant observation were performed and audio-taped. Results: Three thematic units are presented: the radiotherapy trajectory, family support and refuge in God and the importance of the multiprofessional team. The adverse reactions such as odynophagia, dysgeugia and weight loss were the ones that stood out the most, being causes of the social isolation of the participant, nonetheless the patient showed optimism and hope, despite the social isolation. Conclusion: The qualitative methodology allowed the whole trajectory of radiotherapy follow-up which made it possible to understand the treatment experience from the perspective of the participant. Despite the adverse reactions, no negative experience with radiotherapy was found. New studies using the qualitative methodology are suggested with groups presenting similar characteristics of the participant, thus providing a better understanding of the topic addressed, as well as the identification and adoption of strategies that aim at improving care and the quality of life of this population, as well.

Peri-operative outcomes following major surgery for head and neck cancer in the elderly: institutional audit and case–control study

Objective

Elderly patients have been consistently shown to receive suboptimal therapy for cancers of the head and neck. This study was performed to determine the peri-operative outcomes of these patients and compare them with those of younger patients.

Methods

In this retrospective analysis, 115 patients aged 70 years or more undergoing major surgery for head and neck cancers were matched with 115 patients aged 50–60 years, and univariate analysis was performed.

Results

Elderly patients had a reduced performance status (p < 0.001) and more co-morbid illnesses (p = 0.007), but a comparable intra-operative course. They had a longer median hospital stay (p = 0.016), longer intensive care unit stay (p = 0.04), longer median tracheostomy dependence (p = 0.04) and were more often discharged with feeding tubes (p < 0.001). They also had a higher incidence of post-operative non-fatal cardiac events (p = 0.045).

Conclusion

Elderly patients with good performance status should receive curative-intent surgery. Although hospital stay and tube dependence are longer, morbidity and mortality are comparable with younger patients.

Premature discontinuation of curative radiation therapy: Insights from head and neck irradiation

Purpose

Factors related to premature discontinuation of curative radiation therapy (PDCRT) are understudied. This study aimed to examine causes and clinical outcomes of PDCRT at our institution by investigating the most common anatomical site associated with PDCRT.

Methods and materials

Among the 161 patients with PDCRT of various anatomic sites at our institution between 2010 and 2017, 36% received radiation to the head and neck region. Pertinent demographic, clinical, and treatment-related data on these 58 patients were collected. Survival was examined using the life-table method and log-rank test.

Results

The majority of patients were male (81%), white (67%), ≥60 years old (59%), living ≥10 miles away from the hospital (60%), single (57%), with Eastern Cooperative Oncology Group score ≥1 (86%), experiencing significant pain issues (67%), and had treatment interruptions in radiation therapy (RT; 66%). The most common reasons for PDCRT were discontinuation against medical advice (33%), medical comorbidity (24%), and RT toxicity (17%). Of the comorbidities leading to PDCRT, 50% was acute cardiopulmonary issues and 43% was infection. The mean follow-up time was 15.9 months, and the 2-year overall survival and disease-specific survival rates were 61% and 78%, respectively. Patients with illicit substance abuse, cardiovascular disease, and Eastern Cooperative Oncology Group score ≥2 had worse survival. A trend toward improved survival with total completed dose ≥50 Gy versus <50 Gy existed (74% versus 44%, respectively; P = .07).

Conclusions

In this largest-to-date, modern analysis of PDCRT, the most common cause of discontinuation was discontinuation against medical advice, which underscores the importance of patient education, optimization of RT symptoms, involvement of social work, and integration of other supportive services early in treatment. Survival remains suboptimal after PDCRT for H&N tumors, with a 2-year overall survival rate of 61%. Completing >50 Gy appears to confer a relative therapeutic benefit.

Is There Any Age Cutoff to Treat Elderly Patients with Head and Neck Cancer? Comparing with Septuagenarians and Octogenarians

With the increase in life expectancy, age is no longer considered as a limitation for treatment. Nevertheless, the treatment of elderly patients with head and neck cancer (HNC) remains controversial. Here, we aimed to review our experience with the treatment for elderly patients, while particularly focusing on the differences among older old patients (septuagenarians vs. octogenarians). We retrospectively reviewed the records of 260 elderly patients who were assigned to 3 groups according to age: 70 years old ≤ group 1 < 75 years old, 75 years old ≤ group 2 < 80 years old, and group 3 ≥ 80 years old. The patients were assessed for comorbidities using the Adult Comorbidity Evaluation (ACE)-27, and the American Society of Anesthesia (ASA) physical status was also compared. Group 1, 2, and 3, consisted of 97, 102, and 61 patients, respectively. No significant difference in demographic data was noted among the groups. However, group 3 showed more comorbidities than groups 1 and 2. With regard to the initial treatment for HNC, radiation therapy (RT) was more frequently performed in group 3 than in groups 1 and 2. Among 7 patients of non-compliant to treatment in group 3, 6 patients had have performed RT. In group 3, a total of 18 patients underwent surgery, including microvascular free flap reconstruction and no significant difference in complications was observed postoperatively compared with group 1 and 2. Moreover, no significant difference was noted in overall survival between the groups, regardless of the treatment modality chosen. In conclusion, octogenarians with HNC should be more carefully managed than septuagenarians with HNC. Surgical treatment can be considered in octogenarians with HNC, if it can be tolerated.

XPD, APE1, and MUTYH polymorphisms increase head and neck cancer risk: effect of gene-gene and gene-environment interactions

In the present study, we investigated the effect of the DNA repair gene polymorphisms XPD Asp312Asn (G>A), APE1 Asp148Glu (T>G), and MUTYH Tyr165Cys (G>A) on the risk for head and neck cancer (HNC) in association with tobacco use in a population of Northeast India. The study subjects comprised of 80 HNC patients and 92 healthy controls. Genotyping was performed using amplification refractory mutation system-PCR (ARMS-PCR) for XPD Asp312Asn (G>A) and PCR using confronting two-pair primers (PCR-CTPP) for APE1 Asp148Glu (T>G) and MUTYH Tyr165Cys (G>A). The XPD Asp/Asn genotype increased the risk for HNC by 2-fold (odds ratio, OR = 2.072; 95 % CI, 1.025-4.190; p < 0.05). Interaction between APE1 Asp/Asp and XPD Asp/Asn as well as MUTYH Tyr/Tyr and XPD Asp/Asn genotypes further increased the risk by 2.9 (OR = 2.97; 95 % CI, 1.16-7.61; p < 0.05) and 2.3 (OR = 2.37; 95 % CI, 1.11-5.10; p < 0.05) folds, respectively. The risk was further increased in heavy smokers with the XPD Asp/Asn genotype and heavy tobacco chewers with XPD Asn/Asn genotype by 7.7-fold (OR = 7.749; 95 % CI, 2.53-23.70; p < 0.05) and 10-fold (OR = 10; 95 % CI, 1.26-79.13; p < 0.05), respectively. We thus conclude that the XPD Asp312Asn and APE1 Asp148Glu polymorphisms increase the risk for HNC in association with smoking and/or tobacco chewing in the population under study.

Treatment Outcomes of Head and Neck Squamous Cell Carcinoma in the Elderly: A Retrospective Study over 7 Years (2003-2009)

BACKGROUND

Head and neck squamous cell carcinoma (HNSCC) is increasing in prevalence as society ages worldwide. However, there are no established treatment protocols for elderly patients, and the threshold for defining "elderly" is undetermined. In this study, we categorized elderly patients (65 years and older) with HNSCC into 2 groups: "young-old," from 65 to 74 years old, and "old-old," 75 years and older, and compared their treatment outcomes.

METHODS

The subjects were 182 patients aged 65 years and older who visited our hospital for HNSCC from 2003 to 2009. We categorized them into 2 groups, young-old (65-74 years) and old-old (75 years and older), and compared the male-female ratio, ratio with underlying diseases, primary tumor sites, disease stage, applied treatments and curative rate. Additionally, for the curative treatment category in both groups, we compared recurrence rate, relationship between recurrence rate and use of concomitant chemotherapy, the 5-year relapse-free survival and the 5-year cause-specific survival.

RESULTS

The ratio of patients with underlying diseases in the old-old group was significantly higher than in the young-old group, but there was no significant difference in curative rate between the 2 (old-old, 81.9%; young-old, 82.7%). The 5-year, cause-specific survival in curative treatment category was significantly lower in the old-old (66.1%) group than the young-old (94.1%) group.

CONCLUSION

Elderly patients of all ages should positively receive curative treatment. We suppose that concomitant chemotherapy is not acceptable in elderly patients. The 5-CSS of the curative treatment category in the old-old patients was significantly lower than in the young-old patients.

Evaluation of Factors in Relation with the Non-Compliance to Curative Intent Radiotherapy among Patients of Head and Neck Carcinoma: A Study from the Kumaon Region of India

INTRODUCTION

Radiotherapy (RT)-based curative regimens for head and neck squamous cell carcinomas (HNSCC) deliver a dose of 66-70 Gray (Gy) over a period of 6-7 weeks, and incomplete treatments are unlikely to result in cure. Non-compliance to RT is major contributory factor to treatment failure.

AIMS

To assess the proportion of patients who do not complete planned treatment after initiation of curative RT. This study also aims to explore a possible relationship of non-compliance due to socio-economic, disease-related and treatment-related factors.

MATERIALS AND METHODS

The records of HNSCC patients treated from January 2012-December 2013 were audited. Data from the treatment records were to collect patient-related, disease-related, and social demographic parameters. Of the patients who had not completed treatment, the reasons behind the same were investigated.

RESULTS

Of the 324 patients of HNSCC who were initiated on radical RT, a total of 76 patients were found to have discontinued treatment without authorization of the treating clinician. There was no significant predilection for treatment non-compliance with regards to patient age, educational status, religion, site of the disease, use of neoadjuvant chemotherapy, or use of concurrent chemotherapy. There tended to be a higher association of treatment non-compliance among patients residing >100 km away from the treatment center, patients hailing from hilly regions, patients without the below poverty line (BPL) card, unemployed patients, and patients with stage IV-A/B disease. Of the 76 patients who did not complete treatment, telephonic questionnaire could be obtained from 54 patients. Causes for non-compliance included preference for traditional healers (22.2%), fear of toxicity (7.4%), logistic reasons (18.5%), financial reasons (24.1%), and lack of interest/faith in RT (5.6%).

CONCLUSION

There is a high incidence of treatment default among patients of HNSCC during RT in this region. The revelation of the higher propensity for treatment default among patients from distant, hilly regions, unemployed, patients without BPL cards, and stages-IVA/IVB highlights the need for specific interventions for these special populations.

Regression Analysis of Non-iatrogenic Factors That Determine Adherence to Radiation Therapy

The aim of this study is to explore non-medical factors that determine withdrawal from radiation therapy. Data from 2,643 patients who received radiotherapy in our Hospital from March 2010 to March 2012 were collected. Using gender, age, stage of the disease, Karnofsky score, aim of radiation therapy, therapy technique, vocation, medical insurance, and educational status as variables, 43 patients who terminated radiation therapy due to non-medical causes and 43 who completed the recommended course in the same period of time were, respectively, allocated to study and control groups. Univariate and 1:1 multivariate conditional logistic regression analyses were used to determine the risk facts for treatment withdrawal. Forty-three patients who withdrew from the therapy received at least one and maximally 26 therapy sessions (median of seven). A significant part of therapy withdrawals occurred during the first week and accounted for 37 % of therapy withdrawals. Univariate analysis showed that vocation, medical insurance, educational status, stage of the disease, Karnofsky score, aim, and technique of radiation therapy were significant determinants of therapy withdrawal. Furthermore, medical insurance status and stage of the disease were also found to be determinants in the multivariate regression analysis. Medical insurance and stage of the disease were found to be the major determinants that affect withdrawal from radiation therapy.

Quality assurance in radiotherapy: analysis of the causes of not starting or early radiotherapy withdrawal

BACKGROUND

The aim of this study was to analyse the reasons for not starting or for early of radiotherapy at the Radiation Oncology Department.

METHODS

All radiotherapy treatments from March 2010 to February 2012 were included. Early withdrawals from treatment those that never started recorded. Clinical, demographic and dosimetric variables were also noted.

RESULTS

From a total of 3250 patients treated and reviewed, 121 (4%) did not start or complete the planned treatment. Of those, 63 (52%) did not receive any radiotherapy fraction and 58 (48%) did not complete the course, 74% were male and 26% were female. The mean age was 67 ± 13 years. The most common primary tumour was lung (28%), followed by rectum (16%). The aim of treatment was 62% radical and 38% palliative, 44% of patients had metastases; the most common metastatic site was bone, followed by brain. In 38% of cases (46 patients) radiotherapy was administered concomitantly with chemotherapy (10 cases (22%) were rectal cancers). The most common reason for not beginning or for early withdrawal of treatment was clinical progression (58/121, 48%). Of those, 43% died (52/121), 35 of them because of the progression of the disease and 17 from other causes. Incomplete treatment regimens were due to toxicity (12/121 (10%), of which 10 patients underwent concomitant chemotherapy for rectal cancer).

CONCLUSIONS

The number of patients who did not complete their course of treatment is low, which shows good judgement in indications and patient selection. The most common reason for incomplete treatments was clinical progression. Rectal cancer treated with concomitant chemotherapy was the most frequent reason of the interruption of radiotherapy for toxicity.